Download:
pdf |
pdfOMB No. 3048-0023
10/31/2015
Print Form
APPLICATION
FOR SHORT-TERM MULTI-BUYER
EXPORT-IMPORT BANK
of the UNITED STATES
EXPORT CREDIT INSURANCE POLICY
Items marked with an asterisk (*) are required fields. Under corporate ownership, provide name of ultimate parent company, if there is a corporate owner. For
number of employees and sales volume, aggregate for the company and all its affiliates2, including corporate owners and subsidiaries.
Tradestyle:
*Exporter Legal Name:
*Total Number of Employees:
*Street Address:
*City:
*State:
Country:
Contact Person:
Position Title:
Phone #:
E-mail:
*Annual Sales Volume:
*Zip + 4:
*Primary Industry NAICS1:
*Does the Exporter have any affiliates2?
Yes
*Minority-owned business:
Yes
No
Decline to Answer
*Women-owned business:
Yes
No
Decline to Answer
*Veteran-owned business:
Yes
No
Decline to Answer
No
1A company’s Primary Industry NAICS codes is the NAICS that accounts for the largest share of sales for the most recently completed fiscal year. The full definition of “primary industry” is set forth at 13 C.F.R. § 121.107.
2Affiliations exist when one individual or entity controls or has the power to control another or when a third party or parties control or have the power to control both. Factors such as common ownership, common
management, previous relationships with or ties to another entity, and contractual relationships may cause affiliation. The complete definition of affiliation is found at 13 C.F.R. § 121.103.
*Corporate Ownership:
Brokerage:
How did you learn about Ex-Im Bank?
Ex-Im Bank City/State Partner
Ex-Im Bank Regional Office
Other
Broker
Bank
U.S. Export Assistance Center
(describe):
1. Primary reason for application:
risk mitigation
2. Coverage Type Requested:
Comprehensive (Commercial & Political)
financing
extend more competitive terms
Political Only
YES
3. Do you have a credit line with a financial institution (exclude overdraft protection and credit cards)
4. Do you have an SBA or Ex-Im Bank Working Capital Loan?
SBA
YES
NO
EXIM
YES
NO
NO
5. Average total of annual export credit sales over the last three years for you and your affiliates: $
6. Do you wish to insure export credit sales made by your affiliates?
Yes
No
(If yes, please refer to “additional named insured” eligibility criteria in question # 26. Answers to all remaining questions must include eligible
affiliates you wish to add.)
7. Product and/or services to be exported & NAICS (if known):
8. Are the products:
New
Used
9. (a) For SBA defined Small Businesses Only: Was each of the products to be covered under the policy
manufactured or reconditioned with more than 50% U.S. content (comprised of all direct and indirect costs
including but not limited to, labor, materials, research and administrative costs, but excluding net profit)?
(b) If the answer to 9(a) is “No” because one or more of your products contains less than 50% U.S. content
then coverage is available for the U.S. content only in each product with less than 50% U.S. content.
Please indicate if you are seeking coverage for products with less than 50% U.S. content.
(c) If the answer to 9(a) is “No” you may also obtain coverage on an aggregated basis for all products on an
invoice, provided that a Content Report is submitted at the time of shipment (please see applicable Fact
Sheet for information on aggregation). Please indicate if you are seeking coverage on an aggregated basis.
YES
NO
YES
NO
YES
NO
YES
NO
* PLEASE NOTE THAT YOU MAY ANSWER “YES” TO EITHER OR BOTH (b) AND (c) ABOVE.
For Non-SBA Defined Small Businesses: Was each of the products to be covered under the policy
(d) manufactured or reconditioned with more than 50% U.S. content (labor, materials and direct overhead, but
excluding net profit)?
10. Do you sell Capital Goods to foreign manufacturers or producers?
YES
NO
(if yes, attach explanation)
11. Are the Products to be covered under the policy:
Manufactured or reconditioned in the U.S.?
YES
NO
Environmentally Beneficial?
Shipped from the U.S.?
YES
NO
Sold to Military entities or Security Forces?
YES
NO
Used to support Nuclear Energy?
YES
NO
Supporting Renewable Energy?
YES
YES
NO
NO
On the U.S. Munitions List?
YES
NO
(part 121 of title 22 of the Code of Federal Regulations)
Note: Your buyers, their guarantors (if any), and end users of the products must be in countries where Ex-Im Bank is able to provide support, see Ex-Im's Country Limitation Schedule
(CLS) at http://www.exim.gov. There may not be trade measures or sanctions against the good produced with the
U.S. export under Section 201 of the Trade Act of 1974. For a list of products and countries with Anti-Duping or Countervailing Duty sanctions, see section AD/CVD Orders available at
http://www.usitc.gov/trade_remedy/731_ad_701_cvd/investigations/active/index.htm. Trade sanctions are product and country specific (i.e., all firms within a country are subject to the
order, unless a specific firm is explicitly excluded).
EIB-92-50
Revised 04/10
< | First Page
Next Page
Previous Page
Last Page | >
Page 1 of 5
OMB No. 3048-0023
10/31/2015
12. Policy Payment Limit Requested:
13. Buyer Types:
$
% Manufacturers
% Wholesalers/Traders
% Retailers
%Service Providers
% Government Agency
14. Projected # of buyers to whom you will offer export credit terms:
15. Enter the percentage of export credit sales by payment and term type projected for the next twelve months:
Payment Type
Terms (# of days) (must total 100%, collectively)
Sight
1-30
31-60
61-90
91-120
121-180
181-270
271-360
Unconfirmed L/C
Open account or Draft
(enter "Cash Against Documents" in the "Sight" column and "Open account/Draft" row)
16. Export Credit Portfolio: Enter amounts for the projected top 10 countries to which you will have export credit sales over the
next 12 months.
Country Export
Credit Sales
Country Export
Credit Sales
17. Identify your three (3) largest buyers:
Name
Country
Export Credit Sales (next 12 months)
18. Year you began:
a) Exporting?
b) Exporting on credit terms (other than cash in advance or confirmed letters of credit)?
19. For the last three years what were your total export credit:
(include factored or insured receivables and attach any comments)
Sales
write-offs
# of accounts written-off
EIB-92-50
Revised 04/10
< | First Page
Next Page
Previous Page
Last Page | >
Page 2 of 5
OMB No. 3048-0023
10/31/2015
20. Highest average amount of export receivables outstanding over the last twelve months:
21. Total export receivables outstanding: $
$
$
current
at
(date should be within 30 days of the application)
$
1-60 days past due
$
61-90 days past due
$
91-180 days past due
180 days past due
22. Number of buyers past due more than 60 days for $10,000 or more:
23. For each buyer over 60 days past due for $10,000 or more, attach an explanation including name of buyer, country,
amount past due, due date, and reason for past due.
24. Name(s) of export credit decision maker(s):
Years of Credit Years of Foreign Credit
Experience
Experience
Title(s):
25. Please submit the following as Attachments:
• Your financial statements for the most recently completed fiscal year (with notes if available)
• Descriptive product brochures (if available).
• Other pertinent information you wish to include.
26. Special Coverages Required: If "none" check
N/A
Add Additional Named Insureds (ANI's). Credit decisions of each affiliate listed must be centralized with the Applicant and
each affiliate must invoice export credit sales in their own name (or tradestyle); if either is not applicable, please attach an
explanation. Questions 7-25 should include export sales of prospective ANI's.
Does each affiliate invoice export credit sales in its own name or trade style?
Yes
Are the credit decisions of each affiliate centralized with this applicant?
Yes
No
No
If "No" provide comment:
Are the products of each affiliate the same as the applicant's products listed in question 7 of this application?
If No, please list the products in question #7.
Yes
No
Affiliate Company/Trade style
EIB-92-50
Revised 04/10
Street Address/City / State / Country
< | First Page
Next Page
Previous Page
Last Page | >
Page 3 of 5
OMB No. 3048-0023
10/31/2015
Services (Please attach a copy of your sample services contract) Services must be: performed by
U.S. based personnel or those temporarily domiciled overseas, and billed (invoiced) separately from
any product sales.
Small Business Policy To be eligible, your company, together with your affiliates, must have had
average annual export credit sales during the preceding three fiscal years not exceeding $7,500,000,
excluding sales made on terms of confirmed irrevocable letters of credit (CILC) or cash in advance
(CIA).
Enhanced Assignment of small business insurance policy proceeds. This is exporter performance
risk protection that may be offered to lenders willing to finance Ex-Im Bank insured receivables.
Please see the Short Term Credit Standards for eligibility and documentation requirements at http://
www.exim.gov/tools/credit-standards.cfm.
Enter Number of Owners of Company:
Warehouse: Please answer the following questions about the warehouse.
Select Warehouse Type:
Warehouse Location:
Owned or controlled by insured
Bonded warehouse
Neither
State (if U.S.)
City:
Country
State/Province
Selected Exclusion: specify transactions you wish to exclude from coverage.
UILC (Unconfirmed Irrevocable Letters of Credit)
Invoices Under $10,000
SDDP/CAD (Sight Draft Documents Against Payment or Cash Against Documents)
Sales of Samples
Sales to Canada
Sales to Subsidiaries and/or Affiliates
Other (please specify):
EIB-92-50
Revised 04/10
< | First Page
Next Page
Previous Page
Last Page | >
Page 4 of 5
CERTIFICATIONS AND NOTICES
OMB No. 3048-0023
10/31/2015
The Applicant (hereafter “Applicant” or “it”) CERTIFIES, ACKNOWLEDGES and COVENANTS to the Export-Import Bank of the United
States (hereafter “Ex-Im Bank”) that to the best of Applicant’s knowledge and belief, after due diligence, the statements set forth below are true
and correct. Any reference below to “this transaction” shall refer to either the individual transaction or the Ex-Im Bank program or Insurance
Policy that is the subject of the application, as appropriate.
A.
Neither Applicant, nor any of its Principals (as defined in the Debarment Regulations identified below), has, within the past 3 years, been:
1) debarred, suspended, declared ineligible from participating in, or voluntarily excluded from participation in a Covered Transaction (as defined in the
Ex-Im Bank and Government-wide debarment regulations, found at 2 CFR Part 3513 and 2 CFR Part 180, respectively) (collectively the “Debarment
Regulations”);
2) formally proposed for debarment from participating in a Covered Transaction, with a final determination still pending;
3) indicted, convicted or had a civil judgment rendered against it for any conduct or offenses described at 2 CFR § 180.800 in the Debarment
Regulations;
4) delinquent on any amounts due and owing to the U.S. Government or its agencies or instrumentalities as of the date of execution of this certification;
or
5) listed on any of the publically available debarment lists of the following international financial institutions: the World Bank Group; the African
Development Bank; the Asian Development Bank; the European Bank for Reconstruction and Development, and the Inter-American Development
Bank;
or
the Applicant has received a written statement of exception from Ex-Im Bank attached to this certification, permitting acceptance of this application
notwithstanding an inability to make all of the certifications in clauses 1) through 5) of this section A.
B.
Applicant has conducted and will conduct reasonable due diligence in connection with this transaction, including checking the System for Award
Management (https://www.sam.gov/portal/public/SAM/) (“SAM”) to determine if parties are excluded from U.S. Government transactions, and the
Specially Designated Nationals (“SDN”) List of the Department of the Treasury, Office of Foreign Assets Control (“OFAC”) (http://www.
ustreas.gov/offices/enforcement/ofac/sdn/). Applicant will not knowingly enter into any sales, leasing or financing agreements in connection with this
transaction with any individual or entity that is listed on the SAM or the SDN List (or is otherwise prohibited from conducting business with U.S. public
and private entities pursuant to OFAC Regulations).
C.
If any funds have been paid or will be paid to any person for influencing or attempting to influence an officer or employee of any agency, a Member of
Congress, an officer or employee of Congress, or an employee of a Member of Congress in connection with this commitment providing for the United
States to insure or guarantee a loan, the undersigned shall complete and submit Standard Form-LLL, “Disclosure Form to Report Lobbying,” (http://
www.exim.gov/pub/ins/pdf/lll.pdf) in accordance with its instructions.
Submission of this statement is a prerequisite for making or entering into this transaction imposed by section 1352, title 31, U.S. Code. Any person who
fails to file the required statement shall be subject to a civil penalty of not less than $10,000 and not more than $100,000 for each such failure.
D.
Neither Applicant nor any agent or representative acting on Applicant’s behalf, has or will engage in any activity in connection with this transaction that
is a violation of 1) the Foreign Corrupt Practices Act of 1977, 15 U.S.C. § 78dd-1, et seq.; 2) the Arms Export Control Act, 22 U.S.C. § 2751 et
seq., 3) the International Emergency Economic Powers Act, 50 U.S.C. § 1701 et seq., 4) the Export Administration Act of 1979, 50 U.S.C. § 2401
et seq., and, 5) the regulations issued by the OFAC. Applicant also certifies that neither Applicant nor any agent or representative acting on Applicant’s
behalf, has been found by a court of the United States to be in violation of any of the foregoing statutes or regulations within the preceding 12 months,
and to the best of its knowledge, the performance by the parties to this transaction of their respective obligations does not violate any of the foregoing
or any other applicable law.
E.
Neither the Applicant nor any agent or representative acting on Applicant’s behalf in connection with this transaction is currently under charge or has
been, within the past 5 years, convicted in any court of any country, or subject to national administrative measures of any country, for bribery of public
officials.
F.
The representations made and the facts stated in this application and its attachments are true and Applicant has not misrepresented or omitted
any material facts. Applicant further covenants that if any statement(s) set forth in this application becomes untrue, or is discovered to have been
untrue when made, Applicant will promptly inform Ex-Im Bank of such change. Applicant further understands that in accepting or approving this
application, Ex-Im Bank is relying upon Applicant’s statements set forth in the application and on the foregoing certifications, and all statements and
certifications to Ex-Im Bank are subject to the penalties for false or misleading statements to the U.S. Government (18 USC § 1001, et. seq.).
NOTICES
The applicant is hereby notified that information requested by this application is done so under authority of the Export-Import Bank Act of 1945, as amended (12
USC 635 et. seq.); provision of this information is mandatory and failure to provide the requested information may result in Ex-Im Bank being unable to determine
eligibility for support. If any of the information provided in this application changes in any material way or if any of the certifications made herein become untrue,
the applicant must promptly inform Ex-Im Bank of such changes. The information provided will be reviewed to determine the participants’ ability to perform and
pay under the transaction referenced in this application. Ex-Im Bank may not require the information and applicants are not required to provide information
requested in this application unless a currently valid OMB control number is displayed on this form (see upper right of each page). Ex-Im Bank reserves the right
to decline to process or to discontinue processing of an application.
Paperwork Reduction Act Statement: We estimate that it will take you about 1 hour(s) to complete this form. This includes the time it will take to read the
instructions, gather the necessary facts and fill out the form. However, you are not required to provide information requested unless a valid OMB control number
is displayed on the form. If you have comments or suggestions regarding the above estimate or ways to simplify this form, forward correspondence to Ex-Im Bank
and the Office of Management and Budget, Paperwork Reduction Project, OMB# 3048-0023 Washington, D.C. 20503.
(Signature)
EIB-92-50
Revised 04/10
(Print Name and Title)
< | First Page
Next Page
Previous Page
Last Page | >
(Date)
Page 5 of 5
| File Type | application/pdf |
| File Modified | 2015-04-07 |
| File Created | 2013-09-16 |